Sem 4 - Case 1
Difficulty Swallowing Stephen Charles, aged 70, is a retired solicitor. He has led an active retirement and is a keen member of the rambling club, grows prize vegetables on his allotment and, is the chairman of the local ‘gourmet society’. By any measure of quality of life, his quality of life would be assessed as good. His quality of life is exceptionally good. Two weeks ago, he developed a sudden severe headache and accompanied by a weakness on his left side. He was admitted to hospital as an emergency, diagnosed as suffering from a stroke caused by a thrombosis and given appropriate treatment. Whilst on the medical ward, Mr. Charles was noted to sound quite “gurgly” when he spoke, especially after drinking a small amount of fluid. He also seemed to have some left sided facial weakness, and at times his speech seemed slurred. The doctor, who examined him, noticed that Mr. Charles was unable to fully purse his lips together, and decided to get a speech and language therapist to assess his swallowing. However, Mr Charles thought the staff were making a lot of fuss over a minor problem. That evening, before Mr. Charles had been assessed, he developed a temperature of 38.2oC, a tachycardia and became hypoxic. The on-call doctor, who was asked to review Mr. Charles, noted that he had course crackles at the right base of the lung and arranged a chest X-ray. Mr. Charles was started on intravenous fluids and antibiotics and the doctor insisted that he be kept nil by mouth until seen by the speech and language therapists the following morning. The next day, Mr. Charles was seen by the speech and language therapist. She noted that he coughed after small sips of iced water, and had a hoarse “wet” voice. She agreed that Mr. Charles should be kept nil by mouth, and suggested that a nasogastric tube be inserted to give Mr. Charles some feeding. This was done, but Mr. Charles found it uncomfortable and complained that it irritated his throat. Over the next week the nasogastric fell out 3 times, and needed to be re-sited by the medical team. By the following week, Mr. Charles chest infection had improved, but the speech and language therapist felt that his swallowing was still un-safe. The doctors looking after Mr. Charles then decided that the nasogastric tube should be replaced with a percutaneous endoscopic gastrostomy feeding tube. Mr. Charles was worried that this was the end of the road as far as his being able to swallow ever again. Subsequently, Mr Charles received some oral and sub-mental exercises to strengthen the swallow. Over time, he began to swallow more safely. The feeding tube was removed and the dietician advised him on "soft" diet. Although he remained reluctant to consult health professionals his view of the seriousness of his health condition was more realistic now. ILOs *To demonstrate a basic knowledge of the assessment of swallowing and its management *To demonstrate knowledge of the anatomy of the face, jaw, throat and oesophagus *To demonstrate knowledge of the basis of stroke / thrombosis and appropriate methods of treatment (revision - not a major ILO) *To demonstrate knowledge of the mechanism controlling swallowing and its failure in certain clinical conditions *To demonstrate knowledge of the nutritional implications of swallowing disorders (i.e. tube feeding and types of diet required for patients with difficulties swallowing) *To demonstrate knowledge of the physiology of mastication, salivation and swallowing *To further consolidate understanding of how health status and quality of life are measured *To understand how interaction with service and professionals can impact on the outcomes of stroke University Resources Please note that these may require you to log in to blackboard to access them. You can visit the full resource page for the case here, otherwise here are some of the main ones. Case Resources *End of life care: Clinically assissted nutrition and hydration - GMC website *Ethics and end of life care for adults in the intensive care unit - Lancet paper *End of life decision making across cultures - Journal of law, medicine, and ethics paper *MRI scan of realtime, normal swallowing *Quality of life: construct and measurement & Illness cognitions (chapter 9) - Health Psychology textbook Lectures *Illness beliefs and the self-regulatory model of illness - Chris Bundy *Oral, pharyngeal and oesophageal physiology - Shaheem Hamdy *Assessing Swallowing Disorders - Emilia Michou *Withholding and Withdrawing Treatment - Soren Holm